Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
How would you approach a pT2 nonseminomatous testicular cancer, embryonal caricnoma with +LVI with persistent b-hcg < 20 post-operatively?
If a patient has had an inguinal orchiectomy and has a persisting b-HCG in a reliable lab (remember that alpha-HCG can cross-react with the alpha chain of LH, so a "good" beta-HCG assay is important, especially as hypogonadal males often have an elevated LH), it suggests clearly that there is residu...
How would you treat a patient with newly diagnosed prostate cancer with low volume bone metastases and extensive lung metastases with a very low PSA (< 5) and no neuroendocrine differentiation on pathology?
Generally, I would treat such a patient with ADT plus abiraterone (or enzalutamide). A recent paper from our group suggested that patients who present with pulmonary mets, without concurrent liver mets, usually have a great prognosis with hormonal therapies. Another interesting phenomenon is that pa...
How would you manage a patient with MSS, KRAS mutated locally advanced rectal adenocarcinoma with a mixed response to neoadjuvant FOLFOX?
If there is new bone marrow involvement, I assume you confirmed this with a bone marrow biopsy? This would be a very unusual location for rectal cancer, so to speak. If you have not done a BMB, I would obtain pathologic proof of bone involvement. That would make this patient stage IV, in which case,...
Would you offer neoadjuvant chemotherapy for a large, but recurrent grade 1-2 myxoid chondrosarcoma of knee which is no longer amenable to limb salvage?
While not directly relevant for this patient, it is also important to keep in mind that RT is quite effective in decreasing LF in chondrosarcoma, particularly in anatomically challenging locations like joints/pelvis/spine where wide margins often cannot be achieved. The benefit of RT (HR 0.23 for LF...
In a patient who experienced less than 90% necrosis after neoadjuvant chemotherapy for localized, high-grade osteosarcoma, do you recommend adjuvant ifosfamide?
What is the best way to approach elevated liver enzymes in patients treated with combination TKI and immunotherapy?
We rely on clinical judgment in this case as both TKIs and immunotherapies can cause elevation of liver enzymes. Currently, the recommendations in case the attribution of the hepatitis is questionable is to hold both drugs and to check the liver enzymes daily; if it improves, then it is likely due t...
How would you treat high risk prostate adenocarcinoma who relapsed after RT and ADT with a very low PSA, widespread mets to bone and soft tissue who is progressing on ADT, docetaxel and carboplatin?
Difficult situation, this patient likely has neuroendocrine differentiation. I would check for markers like NSE, chromogranin if positive, then can make the case of treating as small cell ca progressed on platinum based chemotherapy and treat with lurbinectedin (Trigo et al., PMID 32224306).PSMA bas...
How and when are you using sipuleucel-T in metastatic prostate cancer given the increase in available treatment options?
At the present time, they do not. The options of treatment in the mHSPC setting include ADT, NHT, and docetaxel only. There are some ongoing clinical trials evaluating the combination of immune therapy with PD-1/PD-L1 checkpoint inhibitors and docetaxel or NHTs currently. Some phase II clinical tria...
Can you use other iron formulations if a patient develops Stevens-Johnson Syndrome with ferumoxytol?
I have never seen it in tens of thousands of doses so it is difficult to answer. If this is actually real, it must be due to CHO component and not Fe (that would be awful). I would use another formulation and premedicate with steroid and H2 blocker before. Do not use antihistamine.
What is the role of preoperative radiation in patients with bone metastases needing surgical stabilization (ie. ORIF), but without tumor resection?
It depends on the patient’s primary diagnosis, extent of disease (multiple metastases vs oligometastastes), and life expectancy. These factors help us formulate a treatment plan on whether we are going to deliver higher ablative doses for patients with longer life expectancy where the ultimate aim i...